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Forms

 

Hardship Request Form

We understand that certain policy owners may face financial hardships as a result of the moratorium that the receivership order placed upon cash surrenders and partial withdrawals, under CBLife policies or contracts. The Court has granted the Special Deputy Rehabilitator authority to consider hardship payment requests. To request a hardship payment, you must complete and return the Hardship Request Form. For the purpose of hardship requests, this form will replace the customary forms that the CBLife previously used for cash disbursement requests.

Hardship Request Form

Accident Medical Expense (AME)

When filing a claim under your Accident Medical Expense policy, please be sure to fully answer the questions on the claimant's statement, including the names, addresses and telephone number of your physicians. Attach a Medical Insurance Summary of Benefits or a bill from your provider of service that itemizes your out-of-pocket expenses and includes the provider's name and address, name of the patient, dates of treatment, diagnosis and charges for services.

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AME Claimant's Statement

Bank Draft Authorization

​Changes to your bank information must be submitted to us in writing. Please fully complete and sign the Bank Draft Authorization Form and submit it to us via email to billing@cblife.com or via fax to 303-267-7599 or via US Mail to; Colorado Bankers Life Insurance Company, PO Box 110604, Durham, NC 27709-0962.

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Bank Draft Authorization Form

Plan Change Form

​This form is used to request an increase or decrease to an annuity rider or stand-alone FPDA product.

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Plan Change Form

Beneficiary Change; Name Change; Owner Change Form

​This is a 3-part form used to change the Owner, the Owner’s Name, and/or the Beneficiary of the referenced policy. Please complete the section(s) corresponding to the desired updates and note that a witness signature is required in order for the change(s) listed to be processed.

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Beneficiary/Owner Name Change Form

Critical Illness Insurance (Critical Condition and Living Benefit)

The following forms apply to the Critical Illness Insurance policy. When you have a claim to file, please complete the claimant's statement and answer all of the questions fully. Have your physician complete and sign the attending physician's statement that is appropriate to your condition. There are specific forms to use if you have had a stroke or heart attack (myocardial infarction).

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Critical Illness Insurance Claimant's Statement
Attending Physician Statement for Critical Illness Insurance
Attending Physician Statement for Heart Attack (Myocardial Infarction)
Attending Physician Statement for Stroke

Paycheck Protection Plus (PPP and Accident Disability Insurance)

The following policy definition must be met to file a claim for total disability benefits on your accident only policy: During the first two years of a loss, means the inability to perform all the substantial and material duties of your regular occupation. After the first two years of a loss, it means the inability to perform the material and substantial duties of any occupation for which qualified by education, training or experience.

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Paycheck Protection Plus Claimant's Statement and Attending Physician's Statement

Monthly Disability Income (MDI)

To be eligible to file a Disability Income claim, you must be totally disabled and unable to work for at least 30 continuous days. The policy premiums must be paid to keep your policy active, and the claim needs to be filed while you are disabled. Please be sure to fully answer the questions on the claimant's statement and have your physician complete and sign the Attending Physician's statement.

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Disability Income Claimant's Statement
Attending Physician's Statement

Social Security Disability for Critical Illness Insurance (SSD)

When filing a claim under your Social Security Disability for Critical Illness Insurance (Critical Condition Accelerated) policy, please be sure to fully answer the questions on the claimant's statement. If you are a resident of a community property state then your marital status and spouse's signature (if applicable) are required.

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Social Security Disability Claimant's Statement
Attending Physician's Statement for Social Security Disability Insurance

Waiver of Premium (WP)

To be eligible to file a Waiver of Premium claim you must be totally and permanently disabled and completely unable to engage in any gainful occupation for at least six continuous months, and the premiums need to be paid to keep your policy in force. Additionally, the claim needs to be filed within one year after the onset of your disability and while you are still disabled.

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Disability Income Claimant's Statement
Attending Physician's Statement

Lost Policy

This form is to request a duplicate policy. A duplicate policy fee of $20.00 is required if the policy has been in effect for a year or more. An Explanation of Benefits will be sent if no fee is received.

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Lost Policy

ConnectwithUs

 

COLORADO BANKERS LIFE INSURANCE COMPANY
PO Box 110604
Durham, NC 27709-0962

Fax: 303.220.8056

Phone: 1.800.367.7814

If you need assistance with your policies or programs,
please call us at: 800.367.7814.

Email: Customer Service Department
Claims Department
Billing Department

Colorado Bankers Life Insurance Company is open Monday through Friday 8 AM to 6 PM Eastern Time.

We observe the following holidays:
New Year’s Eve Day, New Year’s Day, Dr. Martin Luther King Jr. Day, Memorial Day, Independence Day, Labor Day, Thanksgiving Day, the day following Thanksgiving, Christmas Eve Day and Christmas Day.